Intranasal formulation of epinephrine for the treatment of anaphylaxis

ABSTRACT

This invention relates to pharmaceutical compositions of epinephrine for delivery to the nasal mucosa and methods of treating a subject in acute severe anaphylaxis, bronchospasm or during cardiopulmonary resuscitation (CPR). The composition further comprising agents, that either prevent localized degradation of epinephrine or enhance its absorption in the nasal mucosa to counter anaphylactic effects, symptoms or complications in a subject.

REFERENCE TO RELATED APPLICATION(S)

This application is a continuation of U.S. patent application Ser. No.13/929,100 filed on Jul. 27, 2013, which claims the benefit of U.S.Provisional Application No. 61/664,790, filed Jun. 27, 2012. The entireteaching of the above application is incorporated herein by reference.

FIELD OF THE INVENTION

The invention relates to pharmaceutical compositions of epinephrinesuitable for intranasal administration and methods of using thecomposition to treat anaphylaxis, bronchospasm, and duringcardiopulmonary resuscitation (CPR).

BACKGROUND OF THE INVENTION

Anaphylaxis is a severe, rapid onset allergic reaction to insect stingsor bites, foods, drugs, allergens, and can be idiopathic orexercise-induced. About 3 million American children suffer from foodallergies (from peanuts, tree nuts, milk, eggs, fish, seafood andgluten) and according to a study released in 2008 by Centers for DiseaseControl and Prevention, there has been about an 18% increase in foodallergy since 1997. Anaphylaxis occurs in about 1-16% of the USpopulation and carries a 1% mortality rate. Epinephrine (adrenaline) isthe uncontested cornerstone for the treatment of anaphylaxis, and can belifesaving (Joint Task Force on Practice Parameters, 2005, J AllergyClin Immunol 115: S483-S523; Lieberman P. 2003, Curr Opin Allergy ClinImmunol 3: 313-318; Simons F.E.R. 2004, J Allergy Clin Immunol 113:837-844). Any delay in administration of epinephrine may be fatal. In2003, 1.4 million intramuscular (IM) doses (EpiPen™) were prescribed inthe United States and it increased to 1.9 million by 2007. About 100-200people die annually in the US from food allergies.

Epinephrine, being the first-line of therapy for anaphylaxis, isavailable only as an injectable dosage form in ampoules or inautoinjectors (e.g., EpiPen™ and Adrenaclick™ Autoinjector). It is wellabsorbed systemically when administered by intramuscular (IM) orsubcutaneous (SQ) routes. Subcutaneous injection has been shown toresult in delayed (slower Tmax) and variable adrenaline absorption andhence not very effective (Simons F.E.R. et al. 1998, J Allergy ClinImmunol 101:33-37). IM injection, on the other hand, is favored over SQroute because of its rapid onset of action (Tmax) of about 3-8 minutes,and the duration of action between 1 and 4 hours. Based on historicaland anecdotal evidence, a 0.3 mg dose of epinephrine, by subcutaneous(SQ) or intramuscular (IM) injection into the deltoid muscle, has beenagreed upon as the dose required for the emergency treatment of adultanaphylaxis. Recent studies have also demonstrated that if 0.3 mg doseis administered IM into the laterus vascularis (thigh) muscle,epinephrine plasma concentrations are higher and occur more quickly thanSQ or IM administration into the deltoid muscle (Joint Task Force onPractice Parameters, 2005, J Allergy Clin Immunol 115: S483-S523;Lieberman P. 2003, Curr Opin Allergy Clin Immunol 3: 313-318; SimonsF.E.R. 2004, J Allergy Clin Immunol 113: 837-844)).

Thus, epinephrine injections are administered either manually or byautomatic injectors preferably by IM route. However, there are manydifficulties associated with manual SQ or IM administration ofepinephrine, as discussed by Frew A. J. 2011, Allergy 66:15-24, thatinclude: (i) well-known patient apprehension related to needle delivery,(ii) incorrect self-administration, (iii) extra-operational step ofdetaching the needle shield before removal of safety cap in syringebased injectors, (iv) possible loss of medication before reaching thetarget muscle, (v) requiring a trained or medical professional toadminister the dose, and (vi) needle-stick injury. In addition, patientsalso find that the device is awkward to carry, especially as a seconddevice is indicated in case of rebound anaphylaxis (20% of cases).Patients are therefore recommended to have at least one autoinjector athome, in the car, and at school or work, but few have them in alllocations. As a result of these difficulties, the majority of at-riskdiagnosed patients either does not fill their prescription for anautoinjector, or are unwilling to use it, instead going to the EmergencyDepartment.

In addition, the currently marketed Epipen™ comes in two fixed doses of0.15 mg for pediatric patients and 0.3 mg for adults, which often forcesphysicians to decide whether to under- or overdose a patient based onweight, especially in children. Hence, there exists a need in the marketfor more convenient, easy delivery of correct dosage form that does notrequire prior training in the use of the device, and increase compliancein persons prone to anaphylaxis. The intranasal formulations of presentinvention can be delivered using a small needle-free nasal spray device,which is simple to operate, easy to (self) administer and require noprior training to deliver therapeutic dose(s) thus enhancing compliancein individuals. Because the device is small, it is also easy to carrythem unobtrusively in the pocket. Importantly, by providing 2 nasalsprays of the present formulation; a higher dose for adults, a lowerdose for pediatric patients and an option to deliver the required dose(based on body weight by repeating the sprays) or a second dose insituations of rebound anaphylaxis, the present invention solves some ofthe important practical limitations of the autoinjector.

Delivery of epinephrine by oral route is also not recommended because ofnegligible bioavailability owing to its rapid and extensive metabolismin the gut and liver. Hence as an alternative approach, Rawas-Qalaji M.M. et al. (2013, J Allergy Clin Immunol. 131(1): 236-38; 2006, J AllergyClin Immunol. 117(2): 398-403 and in WO2011109340) attempted to deliverepinephrine via the sublingual (SL) route. The authors used a very largeloading dose of SL epinephrine (40 mg) probably due to its mucosalenzymatic degradation by COMT, as well as poor intrinsic mucosaltransportation due to the strong vasoconstriction caused by epinephrineitself. The study further revealed that SL doses ranging from 5 to 40 mgepinephrine, as the bitartrate salt, could achieve plasma concentrationsequivalent to IM injection. Despite the promise of this needle-freedelivery approach, the disadvantage of vomiting associated withanaphylaxis and the panic in anaphylacting patients is a seriousconstraint to its practical use, making it highly unlikely that the SLtablet will stay in place under the tongue for sufficient time to betherapeutically effective. The intranasal spray formulations of thepresent invention, on the other hand, allows for a pharmaceutical doseto be delivered easily by the caretaker or patient as required andwithout major difficulties or undesired effects.

Early methods of nasal drug delivery employed relatively harsh methodsto transport drugs across the nasal mucosa, including the use ofdamaging permeation enhancers such as bile salts. Consequently, many ofthe nasally delivered drugs were traditionally limited to nasalconditions such as rhinitis and nasal allergies, where the drugs acttopically on the nasal mucosa rather than enter the systemiccirculation. More recently, however, systemically acting nasallyadministered drugs, have been successfully developed.

The potential for delivering aqueous epinephrine solution via nasalmucosa route using a needleless high-pressure injection device wasattempted by Yamada T. 2004, Anesth Prog 51: 56-61 in dogs. Using thisdelivery approach, the author reported achieving a peak (Tmax)epinephrine levels of ˜20 ng/mL in the blood at 15 seconds. The peaksystolic pressure was 200% of baseline at 60 seconds and maintained forabout 180 seconds, confirming physiological effects of epinephrine. Yet,this type of delivery is painful resulting in poor compliance andlimited routine clinical utility. On the contrary, the intranasalformulation of the present invention is painless as it is delivered as anasal spray, further contributing to enhanced patient compliance.

Pulmonary delivery of systemic epinephrine has been explored by HeilbornH. et al. 1986, J Allergy Clin Immunol. 78(6): 1174-79. The studycompared the effects of high-dose pulmonary inhalation of epinephrine(i.e., 1.5 to 4.5 mg and 10 to 30 inhalations over several minutes froma metered-dose aerosol) versus subcutaneous injection in human subjects.The results showed that inhalation of 2 to 3 mg of epinephrine producesa gradual increase of epinephrine concentrations in plasma and hence maybe beneficial to counteract the effects of bronchoconstriction innight-time asthma. Bronchomist™ was approved for this indication as aninhaled epinephrine mist. However, similar studies by Simons F. E. R. etal. 2000, Pediatrics 106(5): 1040-44 tested whether this could be usedfor anaphylaxis patients, and concluded that the number of inhalationsrequired especially for children, the length of time to reach athreshold Tmax, and the unpleasant taste, made the pulmonary inhalationdelivery route unacceptable for treating anaphylaxis. By providing anintranasal formulation that contains taste-masking agents and an optimaldose of epinephrine required to reach a Tmax equivalent to IMadministered epinephrine, the present invention has overcome thelimitations noted by the above-mentioned art.

The important intranasal epinephrine studies were conducted by Bleske B.E. et al. 1996 Am J Emerg Med 14: 133-38, who showed the systemicadministration of epinephrine by the nasal route, for treatment of dogsduring cardiopulmonary resuscitation (CPR). Although these authorsobserved a dose response, the absolute bioavailability appeared to bequite low, despite the use of 1% taurodeoxycholic acid solution (bilesalts), which is now known to be a damaging mucosal permeation enhancer.Moreover, to minimize the severe local vasoconstriction caused byepinephrine that could potentially limit the mucosal absorption ofepinephrine, they used pretreatment with intranasal phentolamine. Thephentolamine pretreatment was administered 1 min prior to intranasalepinephrine dosing to enhance epinephrine absorption. To prevent itslocal degradation on the external nasal mucosa, the investigators usedlarge loading doses of phentolamine ranging from 0.25 to 2.5mg/kg/nostril, which amounts to 15 mg for a dog weighing 21 kg. Theloading doses of epinephrine studied were 0.075, 0.75 and 7.5mg/kg/nostril, which amounts to 157 mg/nostril for a dog weighing 21 kg.The greatest cardiac effects and the greatest epinephrine plasmaconcentrations of about ˜1,400 ng/mL were observed at 0.25 mg/kg/nostrilof phentolamine and 7.5 mg/kg/nostril of epinephrine. For optimaltreatment the authors used 7.5 mg/kg/nostril of epinephrine with 1%taurodeoxycholic acid as permeation enhancer after pretreatment with0.75 mg/kg/nostril in about 1 ml each application. Although this studyrevealed the systemic delivery of epinephrine by the nasal route ofadministration, it had significant limitations for translation intoclinical practice, including: (i) dosing that was not optimized, and itis also unclear whether phentolamine was used at its lowest level withno or minimal systemic exposure (which would have competed withepinephrine actions); (ii) the staged pre-dosing of phentolaminefollowed by epinephrine, which is totally impractical for real-worldemergency treatment; (iii) the use of a very large loading dose ofepinephrine (157 mg/nostril for a dog weighing 21 kg) and vasodilator(15 mg/ nostril for a dog weighing 21 kg); (iv) use of large volumessuch as 1.0 mL of solution per nostril and even at that volume, theepinephrine was noticed to crystallize out; this large volume in eachnostril is also impractical for modern nasal aqueous sprays which useonly 100-250 μl volume, and even at this lower volume quite asignificant percentage of the aqueous dose slides off the more densenasal mucosa and is swallowed; (v) the use of bile salts as mucosalpermeation enhancers caused severe nasal mucosal tissue damage, andraises the question to what extent was the systemic delivery achieveddue to the destruction of this tissue barrier, rather than by the actualpenetration by epinephrine. This safety aspect of the study was a fatalflaw for clinical translation of this technology. This technology haslain dormant with no follow-up studies of any kind since 1996.

A nasal spray with a high loading dose of epinephrine (5 mg) was givento normal human subjects and was compared with intramuscular epinephrinein a recent study by Nakponetong K. et al. 2010, J Allergy Clin Immunol125(2): Abstract 859. The study revealed a peak plasma concentration(Tmax) reached in 70±17 minutes. A Tmax of 70±17 minutes even at thehigher loading dose of epinephrine, is insufficient to be of any utilityin anaphylactic shock. Paradoxically, the data on the PK of the IMepinephrine injection with a Tmax of 69±19 minutes is also unacceptable.

Epinephrine formulations delivered by dry powder inhaler, which targetsnasal mucosa of a subject and administered by breath-activated devicesare described in two U.S. Pat. Nos. 7,954,491 and 7,947,742. However,such delivery of epinephrine may not be practically feasible in personsalready in anaphylactic shock. Patient-activated devices are simply notsuitable for treating children in an emergency anaphylactic setting. Nosuccessful systemic delivery or formulations were described.

Hence, despite the theoretical promise for the intranasal route fordelivering epinephrine, there is a need for novel approaches forimproving the intranasal (IN) epinephrine formulation for the treatmentof anaphylaxis. As noted above, the investigation by Bleske B. E. et al.1996 also had a number of significant practical limitations thatprevented their clinical translation. And the lack of any successfulfollow-on studies has left this advance of 1996 frozen in time.

The present invention, however, has solved all the critical limitationsof the above-mentioned art, especially the Bleske study. The firstinnovation is formulation. The formulation of the present inventionpermits lowering the epinephrine loading dose by the optional additionof a reversible topically-acting COMT inhibitor (to prevent epinephrineenzymatic degradation at the nasal mucosa), which may be co-administeredwith a low dose of a topically-acting vasodilator (phentolamine, to stopinhibition of mucosal transport by gross vasodilation) with epinephrineat the same time in the same dose. Added to these are one or more orcombination of mucosal transit slowing agents, and modern permeationenhancers that are non-toxic to nasal tissues. The second innovation isto deliver this as a powder formulation, which itself is muco-adhesiveand aids in mucosal dissolution and absorption. The resulting nasalroute of administration to achieve systemic epinephrine in therapeuticdoses sufficient to treat anaphylaxis, bronchospasm and coronary arrestis: (i) painless (no needle-phobia); (ii) easy to (self) administer orto have a caregiver administer; (iii) uses practical small doses ofintranasal epinephrine formulation containing epinephrine, avasodilator, COMT inhibitor, mucosal transit slowing agents, and modernpermeation enhancers that are not toxic to nasal tissues.

The present invention represents the first major step forward in nasalepinephrine delivery since Bleske in 1996 and is neither anticipated noris obvious to those with ordinary skills in the art.

SUMMARY OF THE INVENTION

Accordingly, the present invention is directed towards a pharmaceuticalcomposition comprising: (i) an anti-anaphylactic agent; (ii) areversible COMT inhibitor to arrest mucosal enzymatic degradation ofepinephrine, which permits use of lower epinephrine loading dose andoptimal solubility limits that does not require unmanageably largeliquid volumes (in case of an aqueous spray) or the physical weight (incase of a dry powder administration); and/or (iii) a vasodilatorsuitable for intranasal administration to elicit a systemic therapeuticresponse during anaphylaxis.

According to the first aspect of invention, the anti-anaphylactic agentin the composition is epinephrine, present in amounts ranging from 0.05mg to 10 mg, preferably from 0.05 mg to 0.75 mg or 0.75 mg to 1.5 mg or1.5 mg to 3.0 mg or 3.0 to 4.5 mg or 4.5 to 6.0 mg or 6.0 to 7.5 mg or7.5 to 9.0 mg or 9.0 to 10.0 mg. In a related aspect, a single dose ofepinephrine given intranasally is bioequivalent to IM or SQ injectedepinephrine (using Epipen™ autoinjector of 0.15 mg for pediatric and 0.3mg for adult patients). In another aspect, the epinephrine dose may beadjusted according to the weight of the patient at an increment of atleast 0.01 mg/kg, or one wherein the dose may be repeated a number oftimes if the patient is refractory or experiences rebound anaphylaxis.The present intranasal epinephrine composition provides an initial risein epinephrine plasma levels which is at least 2-fold, preferably 3 to10-fold more than baseline levels, within 20, 15, 10, 5 and 3 minutes(Tmax), followed by a sustained therapeutic efficacy of the drug for atleast 60, 50, 40, 30 minutes after administration.

In addition to epinephrine, the intranasal pharmaceutical composition ofthe present invention comprises a reversible COMT inhibitor and/or avasodilator. In a preferred embodiment, the reversible COMT inhibitor inthe intranasal composition of the present invention is entacapone,present in the amounts between 0.001 mg (or 1 μg) and 10 mg, preferablyfrom 0.001 mg to 0.01 mg or 0.01 mg to 0.05 mg, 0.05 to 0.1 mg, 0.1 to0.5 mg, 0.5 to 0.75 mg, 0.75 mg to 1.5 mg or 1.5 mg to 3.0 mg or 3.0 to4.5 mg or 4.5 to 6.0 mg or 6.0 to 7.5 mg or 7.5 to 9.0 mg or 9.0 to 10.0mg. In a yet another preferred embodiment, the vasodilator in theintranasal composition is phentolamine, present in the amounts between0.001 mg and 10 mg, preferably from 0.001 mg to 0.01 mg or 0.01 mg to0.05 mg, 0.05 to 0.1 mg, 0.1 to 0.5 mg, 0.5 to 0.75 mg, 0.75 mg to 1.5mg or 1.5 mg to 3.0 mg or 3.0 to 4.5 mg or 4.5 to 6.0 mg or 6.0 to 7.5mg or 7.5 to 9.0 mg or 9.0 to 10.0 mg. These sub-clinical doses of theenabling agents are designed so as to prevent appreciable entry intosystemic circulation, and thus to act only topically on the nasalmucosa. In another related aspect, the intranasal epinephrinecomposition of the present invention may further comprise one or more orcombination of additional agents selected from the group of epinephrinepotentiator, a mucosal permeation enhancer, an agent that reducesmucosal transit time, an agent that increases mucosal absorption oradhesion or transport, surfactants, chelators, pharmaceuticallyacceptable excipients, non-sulfite stabilizers, preservatives,thickening agents, humectants, antihistamines, solubilizing agents,taste and smell masking agents, antioxidant enzymes, viscosity enhancingagents, dispersing agents, colorants, or any combination thereof.

In a second aspect of the invention, the intranasal composition inaccordance with the present invention can be aqueous or dry powdercomposition. In a preferred aspect, the composition is administered inthe form of dry powder due to its many advantages over aqueous nasalformulations, which include but are not limited to: (i) API stability,especially in a mixture which can be challenging to find a commonaqueous buffer that permits maximal stability of unstable APIs; (ii) thepowder easily incorporates into the nasal mucous layer and increases theabsolute nasal residency time of the API, while an aqueous nasal spraywill more likely encounter the mucous layer and due to the densitydifferences, simply slide off into the throat, and not deliver the APIto the nasal mucosa; (iii) dry powder formulations permit the API toimmediately embed into the mucosal layer and then dissolve, causing aneffective concentration gradient for the drug across the mucosalmembrane; (iv) as a dry powder, it permits further incorporation of anasal mucosal permeation enhancer, a epinephrine potentiator, an agentthat reduces mucosal transit time, an agent that increases mucosalabsorption or adhesion, and or an agent that enhances mucosal transport.Powder nasal administration is a very recent development in nasal drugdelivery and was not anticipated in the time of Bleske's studies.Furthermore, there are a large number of modern and safe nasalpermeation enhancers available that can replace the toxic bile acidsused in the original studies.

Accordingly, the dry powder composition is prepared in amounts of up to100 mg, preferably from 10 to 20 mg or 20 to 40 mg or 40 to 60 mg or 60to 80 mg with median particle diameter of up to 30 μm and containing anypharmaceutically acceptable carrier, such as lactose or any one or moreor combination of enabling agents that promote adhesion or absorption tonasal mucosa such as mucoadhesives or mucosal transit slowing agents ormucosal absorption and permeation or penetration or transport enhancers.The active ingredients of powdered composition can be substantiallyamorphous or crystalline. In some preferred embodiments, the shape ofthe particles is diverse.

In yet another embodiment, the active ingredients (epinephrine,reversible COMT inhibitor and/or vasodilator and one or more enablingagents) are nanoformulated or not nanoformulated. Nanoformulation for aliquid formulation that is reconstituted shortly prior to use isdesigned to overcome the solubility limits to ensure that the resultingaqueous volume is kept to the minimum, optimally 100-250 μl. When thecomposition is present in the form of nanoparticles it could bereconstituted in a pharmaceutically acceptable liquid prior to use,optionally where the liquid contains one or more pharmaceuticallyacceptable excipients. If the composition is dissolved in aqueousmilieu, it contains one or more pharmaceutically acceptable excipientssuch as: epinephrine potentiator, a mucosal permeation enhancer, anagent that reduces mucosal transit time, an agent that increases mucosalabsorption or adhesion, an agent that enhances mucosal transport, abuffer, tonicifier, stabilizer, viscosity enhancing agent,preservatives, colorants or any combination thereof to adjust pH andosmolarity.

In a third aspect, the present invention provides a pharmaceuticalproduct, comprising apparatus for intranasally administering apharmaceutical dose or dose form in accordance with the pharmaceuticalcomposition of the invention. The apparatus can comprise a reservoir andmeans for expelling the pharmaceutical dose in the form of a spray,wherein a quantity of the pharmaceutical composition is contained withinthe reservoir. In an embodiment, the apparatus comprises a pump spraydevice in which the means for expelling a single or multiple dosescomprises a metering pump, or a sterile single dose disposable device.The dose to be delivered is typically metered by the spray pump, whichis preferably finger or hand-actuated. In some embodiments, the deviceis programmed to dispense one or more pharmaceutical dose. The nasalspray is designed for discharge of multiple spray doses, e.g., 1 to 10or more. It may be designed to administer the intended dose withmultiple sprays, e.g., two sprays, e.g., one in each nostril, or as asingle spray, e.g., in one nostril, or to vary the dose in accordancewith the body weight or maturity of the patient. The object of thedesign of the safety spray device is to assure to the extent possiblethat a consistent loading dose of epinephrine, which is the bloodequivalent of IM or SQ administered epinephrine dose (0.15 mg inpediatric and 0.3 mg in adults) is delivered to the bloodstream tocounteract the anaphylactic effects in a subject.

In a further aspect, the composition may also be administered using anasal metered dose spray, metered dose inhaler or measured dose inhaler.In another aspect, when the composition is aqueous, volumes of up to 200μcan be delivered using a pharmaceutical aerosol device.

In a yet further aspect, the present invention is also directed towardsa composition for single or multiple use dosage unit form, including asterile disposable dosage form that contains no preservatives.

In a fourth aspect pharmaceutical compositions, doses or products inaccordance with the present invention are useful in the treatment ofanaphylaxis, bronchospasm or cardiac arrest in subjects or forincreasing mean arterial pressure in subjects outside ER or situationsin battlefield or hypotensive shock. They also provide a fast onset timeand are suitable for intranasal use. Although not wishing to be bound byany particular theory, it is considered that the capacity ofcompositions in accordance with the present invention for providing highblood plasma epinephrine concentrations rapidly after administration.

Accordingly, the present invention is also directed toward methods fortreating anaphylaxis in an individual, comprising, applying to themucosal surfaces of the nasal cavities of an individual (the mucosalsurfaces of the anterior regions of the nose, the frontal sinus and themaxillary sinuses and on each of the mucosal surfaces which overlie theturbinates covering the conchas) any of the above describedpharmaceutical compositions by administering a nasal epinephrine loadingdose (i.e., the amount of epinephrine administered nasally which resultsin the systemic blood bioequivalent of intramuscularly administeredEpiPen™, for the 0.15 mg and 0.3 mg doses of EpiPen™) In a relatedaspect, the method of treating a patient with anaphylaxis orbronchospasm in need of treatment from a nasal loading dose of about0.05 mg to about 10 mg of epinephrine, about 0.001 mg (or 1 μg) to about10 mg of a vasodilator, about 0.001 mg (or 1 μg) to about 10 mg of areversible COMT inhibitor, and about 0.001 mg (or 1 μg) to about 10 mgof a epinephrine potentiator a mucosal permeation enhancer, an agentthat reduces mucosal transit time, an agent that increases mucosalabsorption or adhesion, an agent that enhances mucosal transport, (orthe enantiomers, diastereoisomers, racemates, prodrugs thereof, and thesalts of such compounds with pharmaceutically acceptable counterions),wherein said amounts are synergistic for the treatment of anaphylaxis,bronchospasm or cardiac arrest.

DETAILED DESCRIPTION OF INVENTION

Unless defined otherwise, all technical and scientific terms used hereinhave the same meaning as commonly understood by one of the ordinaryskill in the art to which this invention belongs. Although any methodsand materials similar or equivalent to those described herein can beused in the practice or testing of the present invention, the preferredmethods and materials are now described. All publications mentioned areincorporated herein by reference. Unless mentioned otherwise, thetechniques employed or contemplated herein are standard methodologieswell known to one of ordinary skill in the art. The materials, methodsand examples are illustrative only and not limiting.

The singular forms “a,” “and” and “the” are used herein to includeplural references unless the context clearly dictates otherwise. Otherthan in the operating examples, or where otherwise indicated, allnumbers expressing quantities of ingredients, reaction conditions, andso forth used in this application are to be understood as being modifiedin all instances by the term “about.” Accordingly, unless the contraryis indicated, the numerical parameters set forth in this application areapproximations that may vary depending upon the desired propertiessought to be obtained by the present invention.

The term anaphylaxis refers to an acute, systemic allergic reaction thatoccurs after an individual has become sensitized to an antigen. It isassociated with the production of high levels of IgE antibodies and withthe release of histamines, which cause muscle contractions, constrictionof the airways (bronchospasm), and vasodilation. Symptoms ofanaphylactic reactions include hives, generalized itching, nasalcongestion, wheezing, difficulty breathing, cough, cyanosis,lightheadedness, dizziness, confusion, slurred speech, rapid pulse,palpitations, nausea and vomiting, abdominal pain or cramping, skinredness or inflammation, nasal flaring, intercostals retractions, etc.Possible complications of severe anaphylactic reaction include airwayblockage, cardiac arrest, respiratory arrest, shock, and sometimesdeath. The intranasal formulations of the present invention can treatanaphylactic shock and/or symptoms and complications arising due toanaphylaxis. In another embodiment, the present intranasal formulationcan be used to increase mean arterial pressure in a subject during CPRor in battlefield situations and hypotensive shock.

“Enabling agents” according to the present invention refers to compoundsor agents that act synergistically with epinephrine to enhance orpromote its action or absorption or adhesion in target tissue to causeamelioration of the anaphylactic symptoms in a subject. Accordingly, theenabling agents include one or more of the following in any combination;a reversible COMT inhibitor, vasodilators, epinephrine potentiators,permeation or penetration enhancers or mucosal absorption or transportenhancers, agents that reduce mucosal transit time, thickeners,anti-histamines and others as described henceforth.

As described earlier, intranasal epinephrine formulations disclosed inprior-art either have no enabling agents in their formulation(Nakponetong K. et al. 2010, J Allergy Clin Immunol 125(2): Abstract859) or use impractical amounts and doses of epinephrine and vasodilatorin their composition (Bleske B.E. et al. 1996 Am J Emerg Med 14: 133-38)to rescue animals from cardiac arrest. It is therefore the primaryobject of the invention to utilize a novel composition of epinephrinethat contain effective doses and volumes of enabling agents that issuitable for intranasal administration to ameliorate specifically theeffects of anaphylaxis, bronchospasm, or cardiac arrest, in a subject.

Accordingly, to achieve the primary objective of the present invention,the composition comprises the following:

(i) The anti-anaphylactic agent in the present invention is epinephrine,such as epinephrine hydrochloride, epinephrine free base, epinephrinemaleate, epinephrine bitartrate, epinephrine methyl ester orhydrochloride, glycosyl epinephrine derivatives, dipavalyl epinephrinederivatives including dipivefrin hydrochloride, dipivalyloxycatecholamine derivatives, and dipivalyl prodrugs, or the enantiomers,diastereoisomers, racemates, prodrugs, and the salts of such compoundswith pharmaceutically acceptable counterions, or any combinationsthereof. In a preferred embodiment, the anti-anaphylactic agent isepinephrine, or its pharmaceutically acceptable salts thereof. In otherembodiments, the anti-anaphylactic agent is epinephrine hydrochloride.In certain other embodiments, the anti-anaphylactic agent is epinephrinemaleate.

In a yet other preferred embodiment, the anti-anaphylactic agentepinephrine is combined with subclinical levels of a reversibleCatechol-O-Methyl Transferase (COMT) inhibitor, which reduces the actionof natural COMT enzymes that degrade epinephrine on the nasal mucosa.Consequently, this allows use of lower epinephrine doses foradministration in the present invention, further reducing local tissueirritation, and other adverse side effects, that are dose-dependent.Reducing the loading dose of epinephrine also reduces the amount of APIneeded, making the solubility limit of aqueous delivery or the mg weightburden of powder delivery, more practical. Inhibiting the action ofnaturally present COMT enzymes is an approach used in the treatment ofParkinson's disease. These patients degrade the powerful Parkinson'sdrug, L-Dopa via COMT and as a counter measure, the FDA approved use ofinhibitors of oral COMT for Parkinson's treatment. In the presentinvention, drug in this class are used in a novel way, to reduce thedegradation of epinephrine by COMT and potentiate or enhance the potencyof epinephrine.

(ii) Accordingly, the FDA approved reversible COMT inhibitor included atsubclinical concentrations, designed to have the minimal systemicexposure and to be acting mainly topically, is selected from the groupcomprising of the nitrocatechols, entacapone or tolcapone, Comtan(entacapone), Stalevo (entacapone plus carbidopa and levadopa) andTasmar (or the enantiomers, diastereoisomers, racemates, prodrugs, andthe salts of such compounds with pharmaceutically acceptable acids andbases). In a preferred embodiment, the reversible COMT inhibitor in theintranasal epinephrine composition is entacapone. In other embodiment,the reversible COMT inhibitor in the intranasal epinephrine compositionis tolcapone.

(iii) The current invention also provides for intranasal formulations ofepinephrine that avoids local tissue vasodilation, observed inepinephrine injections. As noted earlier, FDA-approved vasodilator isadded at subclinical concentrations to reduce the nasal vascularvasoconstriction caused by epinephrine and allows faster flux across themucosal membrane, designed to have the minimal systemic exposure and tobe acting mainly topically. This further enables use of lower loadingdoses of epinephrine, thereby reducing dose-related adverse sideeffects.

Accordingly, the vasodilators added to the present formulation of theinvention are selected from but are not limited to older vasodilators,(i.e., hydralazine, isosorbide mononitrate, isosorbide dinitrate) ACEinhibitors (i.e., Benazepril (Lotensin), Captopril (Capoten), Enalopril(Vasotec), Fosinopril (Monopril), Lisinopril (Prinivil, Zestril),Minoxidil (Loniten), Meoexipril (Univasc), Perindopril (Aceon),Quinapril (Accupril), Ramipril (Altace), Trandolaptril (Mavik)), andAngiotensin II receptor agonists (A2 inhibitors) (i.e., Losartan,Candesatran, Valsartan, Irbesartan, Telmisartan, Eprosartan, Olmesartan,Azilsartan), and others including papaverine hydrochloride orphentolamine mesylate, selected from: cocaine; ethyl nitrate;nitroglycerine; diltiazem; urapidil; nicorandil; sodium nitroprusside;glyceryl trinitrate-verapamil; phenoxybenzamine; dopexamine;chloropromazine; propiverine hydrochloride; (or the enantiomers,diastereoisomers, racemates, prodrugs, and the salts of such compoundswith pharmaceutically acceptable acids and bases. In a preferredembodiment, the vasodilator present in the intranasal composition isphentolamine.

The present invention also contemplates adding to the formulation one ormore or combination of the following enabling agents:

(a) Epinephrine potentiators that improve or enhance the pharmacologicalaction of epinephrine. Such potentiators are selected from the groupcomprising of guanethidine, selected from NAC; isoproterenol;norepinephrine; hydrocortisone; flavonoids (vitamin-P like compounds;local anesthetics; vasopressin; cocaine; methylphenidate;tripelennamine; bufozenine; harmine; mescaline; LSD; methergine;ganglionic blockers; antihistamines; amphetamines, or the enantiomers,diastereoisomers, racemates, prodrugs, and the salts of such compoundswith pharmaceutically acceptable counterions, or any combinationthereof. Other agents that potentiate epinephrine responses byinhibiting its degradation by COMT include tropolone, desmethylpapaverine and pyrogallol. Certain amino acids, including histidine inthe presence of tissue cupric ions, also potentiate epinephrine action.

Further, compounds such as flavinoids (Vitamin P-like compounds), localanesthetic agents, vasopressin, cocaine, methylphenidate (Concerta theCNS stimulant for ADHD), tripelennamine, bufotenine, harmine, mescaline,LSD, methergine, ganglionic blockers, antihistamines (norepinephrine),and amphetamines may also be used to potentiate epinephrine.

(b) Permeation enhancer as used herein, refers to one or mixture ofsubstances which when formulated with anti-anaphylactic agent, such asepinephrine have the effect of increasing the fraction of theepinephrine applied to the nasal mucosal surface that traverses themucosal membrane and enters bloodstream, i.e., increasesbioavailability. Generally, the addition of a permeation enhancer toepinephrine formulation designed for intranasal administration willincrease the fraction of epinephrine that reaches the circulation by atleast about 25%, preferably at least 50%, and most preferably at least100%. Many such permeation enhancers are known, as described herein. Thepresent invention contemplates adding nasal permeation or nasalpenetration enhancers such as bile salts, alkyl glycoside, polymer,tight junction modulating peptides as described in WO2007014391 A2,lipids, surfactants, cyclodextrin, or chelators, or any combinationthereof. Cyclodextrins can have various functions in the intranasalformulation, including taste masking, drug solubilization, and drugstabilization. Cyclodextrins have also been found to have unexpectedsynergistic effects when combined with certain permeation enhancers.Examples of pharmaceutically acceptable cyclodextrins includealpha-cyclodextrin, beta-cyclodextrin, gamma-cyclodextrin,hydroxypropyl-beta-cyclodextrin, and sulfobutylether beta-cyclodextrin.In certain embodiments, ‘Hsieh enhancers’ described in U.S. Pat. Nos.5,023,252 and 5,731,303 or cyclic lactones or cyclic diesters or cyclicketones described in WO2011153400 A2 can be added as permeationenhancers.

Example lipids for permeation enhancement include, but is not limitedto, 1,2-Dioleoyl-sn-Glycero-3 Ethylphosphocholine,1,2-di-O-phytanyl-glycero-3-phosphocholine,1-O-hexadecyl-2-acetoyl-sn-glycerol,1-O-octadecyl-2-O-methyl-glycerol-3-phosphocholine, 16:0-09:0(ALDO)PC,16:0-09:0(COOH)PC, 3-beta-hydroxy-5alpha-cholest-8(14)-en-15-one, C10sucrose, C12 maltose, C12 sucrose, C14 maltose, C16-09:0, C6 glucose, C6maltose, C7 glucose, C8 glucose, Cardiolipin (sodium salt), Ceramide(brain porcine), Ceramide C10:0, Ceramide C12:0, Ceramide C14:0,Ceramide C16:0, Ceramide C17:0, Ceramide C18:0, Ceramide C18:1, CeramideC20:0, Ceramide C24:0, Ceramide C24:1, Ceramide C2:0, Ceramide C4:0,Ceramide C6:0, Ceramide C8:0, Cerebroside (brain porcine), CerebrosideSulfatide (porcine), Dimethylsphingosine, Egg Ceramide, Galactosylsphingosine, Glucosyl-sphingosine, Lactosyl(B) Sphingosine, Lyso-PAF,N-acetoyl ceramide-1-phosphate, N-octanoyl ceramide-1-phosphate, PGPC1,POVPC, Phosphatidylinositol (Soy), Phosphatidylinositol (bovine),Platelet-Activation Factor, Porcine brain ganglioside, Sphingomyelin(brain porcine), Sphingosine-1-phosphate, and trimethylsphingosine.Preferred lipids in this context are those classified as glycosylatedsphingosines, alkylglucosides, oxidized lipids, and ether lipids (PAF).

We have found that a variety of commonly used and generally accepted assafe (GRAS) pharmaceutical excipients act synergistically to increaseepinephrine permeation across the nasal mucosa. Said excipients can bedemonstrated by their ability to improve epinephrine permeation invitro, for example in a in vitro tissue model to human mucosa, and alsoin vivo, for example, animal pharmacokinetic studies. Alternatively, wehave also found that near-GRAS and non-GRAS excipients can actsynergistically upon the nasal mucosa to increase transmucosalpermeation of epinephrine.

It will also be appreciated that permeation enhancers suitable for usein the formulation of drug preparations that enter the bloodstream viathe GI tract also potentially may be adapted for use in the presentinvention. These, without limitation, include those disclosed in US20030232078, such as ethylene-diamine tetra-acetic acid (EDTA), bilesalt permeation enhancers such as those noted above and fatty acidpermeation enhancers, such as sodium caprate, sodium laurate, sodiumcaprylate, capric acid, lauric acid, and caprylic acid, acyl carnitines,such as palmitoyl carnitine, stearoyl carnitine, myristoyl carnitine,and lauroyl carnitine, and salicylates, such as sodium salicylate,5-methoxy salicylate, and methyl salicylate. U.S. Pat. Nos. 4,548,922and 4,746,508 also discloses a system for delivering proteins andpolypeptides by intranasal or other transmucosal routes using lowtoxicity permeation enhancers of the amphiphilic steroid family, e.g.fusidic acid derivatives, to promote efficient transport of the drugacross the mucosal surface.

For permeation enhancement of epinephrine, the actual effectiveness ofan enhancer shall be verified by routine experiments of a nature wellknown to the skilled artisan, e.g., using the porcine, dog, or ratmodel. The amount of permeation enhancer included in the epinephrineformulation of the present invention, will generally range between about1 wt % to about 30 wt %. The precise nature and amount of enhancer willvary depending on, for example, the particular permeation enhancer orenhancer composition selected, and on the nature of other components inthe formulation, such as its potency. The upper limit for enhancerconcentration is set by toxic effect to or irritation limits of themucosal membrane or its solubility limits.

(c) Mucosal absorption or transport enhancers, mucosal transit slowingagents and mucoadhesives—Because mucosal membranes provide a protectivebarrier against the outside environment and are lined by epithelialcells which provide a barrier to the entry of toxins, bacteria andviruses, agents that aid or promote absorption and/or transport oftherapeutic agents by getting past the protective barrier are often usedin pharmaceutical compositions. Absorption agents used to date includesurfactants, gelling microspheres and the bioadhesive polymer, chitosan.Examples of these systems have been reviewed by Ilium L. and Fisher A.M. in “Inhalation Delivery of Therapeutic Peptides and Proteins,” Adjeiand Gupta (eds.) Marcel Dekker Inc., New York (1997), 135-184 and byConstantino H. R. et al. Intranasal delivery: Physicochemical andTherapeutic Aspects, Int J Pharm, 337, 2007, 1-24. The present inventioncontemplates adding one or more or combination of the afore-mentionedabsorption agents or others including sodium lauryl sulfate, sodiumsalicylate, oleic acid, lecithin, dehydrated alcohol, Tween, Span,polyoxyl 40 stearate, polyoxyl ethylene 40 stearate, propylene glycol,hydroxyl fatty acid ester of polyethylene glycol, glycerol monooleate,fusieates, bile salts, octoxynol, polysorbate 20, polysorbate 80, DDPC,DPPC, a chelator such as EDTA, EGTA, or citrate, and combinationsthereof; or one selected from the group consisting of anionic, cationicand nonionic surfactants. The term enhancer as used in the inventionalso encompasses substances that are capable of modulating the barrierfunction of a cellular tight junction.

Since the typical residence time of proteins and other macromolecularspecies delivered is limited at the nasal mucosa due to rapidmucociliary clearance, e.g., to about 15-30 minutes or less, in someembodiments, substances, compounds or peptides that reduce nasal mucosaltransit time can be included in the intranasal epinephrine compositionof the present invention. For instance, polyacrylate mucoadhesive agentsare known to slow the rate of gastric transit thereby maximizingefficiency of both the protective effect and the time required fordelivery of repair agents into the underlying tissue. The presentintranasal epinephrine formulation contemplates adding such polyacrylatemucoadhesive agents as disclosed in WO2003037355A1 or similar agents orsubstances (synthetic or natural) or peptides alone or in combination,that is compatible with epinephrine administration and can slow the rateof nasal transit and maximize the absorption of epinephrine in the nasalmucosa.

Alternatively, the intranasal epinephrine composition of the presentinvention can include modulatory agents of epithelial junctionphysiology, such as nitric oxide (NO) stimulators, chitosan and chitosanderivatives.

To promote adhesion of the active ingredients of the pharmaceuticalcomposition, present invention also contemplates adding mucoadhesiveagents to the intranasal composition. As used herein, mucoadhesion is aproperty whereby a natural or synthetic substance, when applied to amucosal epithelium adheres to or penetrates a subjects's mucosalmembrane, in this invention nasal mucosal membranes, for a period oftime sufficient to quantitatively deliver an anti-anaphylacticcomposition provided herein to the subject.

Generally, although not exclusively, adhesion of mucoadhesives to amucous membrane occurs via secondary chemical bonds, such as hydrogenbonding and Van der Waal forces (Tabor D. 1977, J. Colloid InterfaceSci. 58:2 and Good R. J. 1977, J. Colloid Interface Sci. 59:398).Non-limiting examples of one or more or combination of mucoadhesiveagents that can be added to the present epinephrine composition includecrystalline cellulose, cellulose derivatives, starch, proteins such asmucin, lactoferrin and transferrins, mucoadhesive polymers such aschitosan or carbopol, polyacrylic acid or derivatives such as carbophil,carbomer, and carbopol 943 or lecithin (Takeuchi H. et al. 2005, AdvDrug Deliv Rev, 57:1583-1594).

(d) Pharmaceutically acceptable excipients selected from the groupcomprising of block copolymers comprising repeating ethylene oxidemoieties, anionic polysaccharides and ion exchange polymeric materials,including excipients selected from the group consisting of pectin,carboxylated starch and gellan.

(e) Viscosity enhancing or thickening agents, especially in nasal drypowder delivery, that can also have other desirable actions on the nasalmucosa for increasing API transport or absorption, dissolution rate, orresidency time (by mechanisms that are not known), selected from thegroup comprising of poly (vinyl alcohol) (PVA), poly (ethylene glycol)(PEG), propylene glycol, and polysaccharides such as soluble starch,various cellulose forms both crystalline and amorphous, methylcellulose,hydroxylpropyl cellulose carboxymethylcellulose, and chitosan.

(f) Because epinephrine has been reported to have an unpleasant tastewhen inhaled (Simons F. E. R. et al. 2000 Pediatrics 106(5): 1040-44),addition of taste-masking agents to the composition is contemplated. Thepresent invention could use a variety of taste-masking agents, includingcyclodextran cages to taste-mask. Other agents for taste maskinginclude, but are not limited to citric acid (up to 20% in a marketednasal solution), sorbitol (up to 2.86% in a marketed metered nasalspray), glycerin (up to 2.5% in a marketed nasal solution), dextrose (5%in a marketed metered nasal spray), and phenethyl alcohol (up to 0.25%in a marketed metered nasal spray, also could serve as a preservativefor multi-use). The following agents approved in buccal/oral/dentalcompositions may also be added in the current formulation: acacia syrup,anethole, anise oil, benzaldehyde, butterscotch, cardamom, cherry (andvarieties thereof), cinnamon, cocoa, coriander, ethyl acetate, ethylvanillin, ginger, glucose, lavender, lemon, maltodextrin, mannitol,methyl salicylate, nutmeg, orange, peppermint, raspberry, saccharin,spearmint, sucrose, sucralose, tolu, vanilla and varieties thereof.

(g) Since sulfites are currently used in all commercially availableepinephrine preparations, and can be anaphylactic in susceptibleindividuals and in individuals with mutations to the sulfatase gene, thepresent formulation of epinephrine is sulfite-free. Thus sulfite-free,non-toxic preservatives for epinephrine (or other oxidizable drugs) thatare non-allergenic and non bronchospasmodic are selected from the groupcomprising of thiols, glutathione, glutathione reductase, glutathioneperoxidase, hydroquinone, amikasin sulfate, apomorphine hydrochloride,metaraminol, levobunonol, levobunonol hydrochloride, acamprosatecalcium, fenoldopam, hydrocortisone/neomycin sulfate/polymyxin B,dexamethasone sodium phosphate, hydromorphone, dobutamine, epinephrine,etidicaine/epinephrine bitartrate, gentamycin, tinzaparin,isoproternerol, ketoconazole, sodium sulfacetamide, norepinephrine,bupivacaine/epinephrine bitartrate, morphine, tobramycin, rotigotine,orphenadrine, procaine, nalbuphine, oxytetracycline, nortriptyline,perphenazine, promethazine hydrochloride, prednisolone acetate,propofol, mesalamine, trimethoprim/sulfamethoxazole,carisoprodol/aspirin/codeine, streptomycin, mafenide acetate,tetracycline hydrochloride, pentazocine lactate, chlorpromazine,triethylperazine maleate, fluorinolone acetonide/hydroquinone/tretinoin,acetaminophen/codeine, doxycline calcium and lidocaine/epinephrine.

(h) Stabilizers/preservatives- commercially available epinephrines todayall contain stabilizers that are themselves bronchodilators orallergenic at least in sensitive patients, especially asthmatics. Theseinclude sodium metabisulfite (0.5 g in EpiPen); and chlorobutanol andsodium metabisulfite (TwinJect™ injection, at unspecifiedconcentrations); or 34% dehydrated alcohol with Vitamin C in PrimateneMist Inhalation Aerosol. The bisulfites, chlorobutanol and alcoholinactive ingredients have all been extensively documented as beingcontraindicated for bronchospasm, and by implication for anaphylaxis orcardiac arrest. The present invention will be the only formulation ofepinephrine on the US market without these bronchospasmodicpreservatives, but with only Vitamin C as a possible stabilizer andbeing sealed in a darkened vial under inert nitrogen. Vitamin C is knownto be harmless in relation to lung function, bronchospasm and asthma.Vitamin C is recognized as the major antioxidant in airway surfaceliquid of the lung, where it is likely protective against toxic oxidantsand likely has this effect on the nasal mucosa.

(i) Anti-histamines that not only act to inhibit COMT but also preventsexplosive mast cell degranulation activity in response to allergens. Theanti-histamines contemplated in the invention include those suitable fornasal application as disclosed in US 20100055152 A1, non-sedatingantihistamines disclosed in issued U.S. Pat. No. 8,263,581 and thosewell known in the art and selected from the group comprising azelastine,hydroxyzine, desloratadine, emadastine, levocabastine, carbinoxamine,levocetrizine, fexofenadine, diphenhydramine, brompheniramine,clemastine, and chlorpheniramine.

(j) Humectants selected from the group comprising of sorbitol, glycerol,mineral oil, vegetable oil, or combinations thereof.

(k) Osmotic adjusting agents, which may be used, include, but are notlimited to, sodium chloride, potassium chloride, zinc chloride, calciumchloride, and mixtures thereof. Other osmotic adjusting agents may alsoinclude, but are not limited to, mannitol, glycerol, and dextrose andmixtures thereof. In an alternative embodiment, the present inventionmay comprise about 0.4 to about 1.0 weight percent ionic salt.Preferably, the present invention comprises about 0.9 weight percent ofan osmotic adjusting agent.

‘Loading dose’ in the present invention refers to the actual amount ofepinephrine administered intranasally and the ‘bioequivalent dose ofintramuscularly (IM) or subcutaneously (SQ) injected epinephrine’ refersto the blood levels and systemic exposure of intranasal epinephrineattained which is the same or equivalent to intramuscular injection atdoses of 0.15 and 0.3 mg in children and adults respectively. ‘Effectivedose’ according to the present invention refers to the epinephrine doserequired to treat anaphylaxis or reduce anaphylactic reactions orsymptoms or complications in a subject.

API (Active Pharmaceutical Ingredients) or “active ingredients”according to this invention include epinephrine, reversible COMTinhibitor, phentolamine and one or more enabling or additional agents ofthe present composition.

‘Baseline levels’ in the present invention refers to epinephrineconcentrations in blood before epinephrine administration by intranasalor intramuscular or subcutaneous methods.

The subject is generally a mammal. If a mammal, the subject may be ahuman, but may also be a domestic livestock, laboratory subject or petanimal.

Modes for Carrying Out the Invention

The intranasal epinephrine compositions of the present invention can bein powder or aqueous formulation.

(a) Powder Formulation

In a preferred embodiment, the composition of the present invention is adry powder formulation, including one selected from the group consistingof simple powder, crystalline or amorphous mixtures, powdermicrospheres, coated powder microspheres, including micronized andnanoformulated powders, and combinations thereof. In a related aspect,particles of epinephrine, entacapone and/or phentolamine and enablingagents such as mucoadhesives, mucosal penetration or permeation,absorption or transport enhancers, mucosal transit slowing agents andpharmaceutically suitable carrier such as lactose contained in thepowder formulation, can be substantially amorphous or crystalline orsemi-crystalline or semi-amorphous or dispersed in nature.

For easy dispensability of the powder formulation the intranasalepinephrine composition of the present invention may further containadditional agents including lubricants such as magnesium stearate, orfluidizing agents such as talc and silicon dioxide. Such lubricants andfluidizing agents are thought to reduce the friction and adhesion amongpowder particles by adhering onto the powder surface and increasing thespace among the particles and, as a result, produce the dispensabilityimproving effect. The powder composition in some embodiments iscolorless. In other embodiments, a non-allergenic colorant may be addedto the composition to aid in the visualization of the dose to bedispensed from the delivery device.

In some embodiments, the shape and size of the powder particles areeither uniform or diverse and are designed to have no negative influenceon their absorption in the nasal mucosa. In some other embodiments, themedian particle diameter can be up 100 μm, preferably between 50 μm and100 μm or between 20 μm and 50 μm. Herein the “median diameter” refersto particles of smaller diameters and those with greater diameters. Inembodiments where the formulation exists as nanoparticles, less than 10%of particles are less than 10 microns in diameter.

The amount of epinephrine present in the dry powder formulation isbetween 0.05 mg and 10 mg, preferably from 0.05 mg to 0.75 mg or 0.75 mgto 1.5 mg or 1.5 mg to 3.0 mg or 3.0 to 4.5 mg or 4.5 to 6.0 mg or 6.0to 7.5 mg or 7.5 to 9.0 mg or 9.0 to 10.0 mg. In some other relatedembodiments, epinephrine represented in the dry powder formulation isbetween 0.25% and 50%. Enabling agents including a reversible COMTinhibitor and/or vasodilator present in the formulation ranges between0.001 mg (or 1 μg) and 10 mg. The total amount of dry powder formulationcan be up to 100 mg, but preferably 50, 30, 20, 10 and 5 mg.

In some embodiments, conventional methods are employed to make asuitable powder formulation. This includes mixing powdery drugs withcarriers and enabling agents for nasal administration by using mortar,mixers, or stirrer. Other methods to make a suitable powder formulationinclude, preparation of a solution of active ingredients and excipients,followed by precipitation, filtration, and pulverization, or followed byremoval of the solvent by freeze-drying, followed by pulverization ornanosizing of the powder to the desired particle size. The final stepcan be sieving to obtain particles with a size of less than 100 μm indiameter, preferably between 50 μm and 100 μm or between 20 μm and 50 μmin diameter. In some embodiments, nasal powder compositions made bymixing epinephrine, enabling agents, including mucosal permeation andpenetration enhancers, agents that increase nasal residency time, andacceptable excipients, can each possess the desired particle size. Oneor more pharmaceutical dose of the dry powder composition of the presentinvention can be administered using a simple hand or finger operatedspray device, nasal insufflator, a jet-spray, or any other conventionaldevice known to skilled artisan in the art.

The powder compositions, in preferred embodiments, may be presented in asterile unit dosage form (for example, in capsules, cartridges, orblister packs) from which the powder may be administered with the aid ofa dry powder dispenser or by numerous other nasal delivery methods wellknown to those skilled in the art.

In certain other embodiments epinephrine is nanoformulated and may bedosed as a reconstituted powder prior to administration, or as a liquidsuspension. Nanoformulation of the drug in the present inventionutilizes readily available and simple fluid bed spray drying method in amanner that produces uniform and stable 40-90 nm drug particles of pureAPI without external excipients. This is important since some methods ofmanufacturing nanopharmaceuticals require the addition of externalnanostructures to the API, which raises potential safety concerns. TheFDA treats nanoformulated or micronized API the same as a raw drug, withno additional safety concerns.

One of the key advantages of nanoformulation is the tiny size of the APIparticles and the vast increase in surface area compared tonon-nanoformulated API. Other advantages of nanoformulation include (i)higher water solubility of drugs that are poorly soluble in water, dueto the increased surface area having a greater exposure to thesolubilizing effects of an aqueous media (ii) drug solubility limits maybe reduced (iii) absence of any food effects, which can limit patientcompliance if a drug must be taken with food or without food (iv)reduced hepatic first pass metabolism by unclear mechanisms and possibly(v) increased rate of membrane transportation because rate-limitingsolubility is diminished.

Moreover, a combination of nanoformulation and nasal delivery ofepinephrine and enabling drugs (vasodilators and reversible COMTinhibitors, permeation and penetration agents, and residency timemodifiers etc.) has surprising synergistic effects on Tmax. Theformulation or the nanoformulation of the present invention, whendelivered nasally is as fast- acting as intramuscularly injectedepinephrine, achieving a Tmax in about 3-8 minutes. This is in contrastto an epinephrine-only formulation which when given as intranasal sprayin human subjects reached an unacceptable Tmax in about 70±17 minutes(Nakponetong K. et al. 2010, J Allergy Clin Immunol 125(2): Abstract859).

(b) Aqueous Formulation

Another aspect of the invention is a composition wherein epinephrine,entacapone and/or phentolamine and the enabling agents are dispersed inaqueous or non-aqueous formulations. In a related aspect, the aqueoussolution is selected from the group consisting of aqueous gels, aqueoussuspensions, aqueous liposomal dispersions, aqueous emulsions, aqueousmicroemulsions, aqueous micronized particles, aqueous nanoparticles andcombinations thereof. Another aspect is wherein the composition is anon-aqueous solution, including one selected from the group consistingof non-aqueous gels, non-aqueous suspensions, non-aqueous liposomaldispersions, non-aqueous emulsions, non-aqueous microemulsions,non-aqueous micronized particles, and non-aqueous nanoparticles andcombinations thereof.

In one embodiment, nanoformulated epinephrine, entacapone and/orphentolamine and enabling agents, including permeation enhancing,absorption and transport enhancing and residency time agents, present inaqueous milieu is used for avoiding first pass metabolism, gainingfaster dissolution rate by increasing the solubility of the activepharmaceutical ingredient, and passing the nasal mucosa at a fasterrate. This is especially important when the dose must be delivered inonly 100-250 μl and such small volume may approach the solubility limitsof the active ingredients.

In related embodiments, the pH of the intranasal aqueous formulation canbe acidic, for example in the range of pH 3 to pH 6. In a related aspectthe pharmaceutical composition comprising an aqueous buffer has a pHfrom about 3 to 7.5 containing a sufficient amount of a therapeuticallyacceptable thickening agent so that the viscosity is from about 2500 toabout 10,000 cps.

For the administration of powder or aqueous compositions to mucosalmembranes, in particular the nasal mucosal membranes, the compositionsaccording to the invention are conveniently delivered by conventionalmeans e.g. in the form of a single dose or multiple dose manual pumpnasal spray. The compositions may also be delivered to the lungs bydirect inhalation by numerous delivery methods well known to thoseskilled in the art, particularly for the treatment of mild bronchospasm,such as asthmatics in night-time bronchoconstriction. For instance, thenasal spray compositions when formulated as pH neutral and isotonicsolutions or suspensions may be delivered by a nebulizer. Anotherembodiment of the invention is a method of nasal delivery that employs asterile premixed formulation containing epinephrine that may be disposedof after use.

In some embodiments the composition is formulated for delivery asaerosol spray especially when the active ingredients are suspended,optionally together with one or more stabilizers. The aerosol spraydevice uses a non-halogenated hydrocarbon propellant, including air,nitrogen, or other gases, or manual pump action to deliver the aerosolspray. In a related aspect, the pharmaceutical aerosol device comprisesthe pharmaceutical composition; a container into which the compositionis placed, and an actuator to produce particles of an aerosol spray outof a tip of the actuator when actuated, wherein the aerosol sprayconsists of droplets, wherein less than 10% of droplets are less than 10microns in diameter. Another aspect is the device, wherein the aerosolhas a spray pattern ellipticity ratio of 1 to 4 when measured at aheight of 0.5 cm to 10 cm distance from the actuator tip. Another aspectis the device, wherein the aerosol spray contains 50 to 500 microlitersof the solution per actuation, wherein the aerosol spray pattern hasmajor and minor axes of 10 to 50 mm when measured at a height of 0.5 cmto 10 cm distance from the actuator tip, or wherein upon actuation anaerosol of the solution is produced through the tip of the actuator,wherein the aerosol is comprised of droplets of the solution that are 10to 500 microns in size.

In some embodiments, controlled release of epinephrine may haveadvantages. Sustained or Controlled Release (CR) can be achieved by avariety of approaches including manipulation of epinephrine to controlits dissolution rate, and/or the composition of the medium in whichepinephrine is suspended. To achieve the sustained or CR, excipientswith mucoadhesive, and/or viscosity enhancing and/or ability toreversibly diminish mucocilliary clearance function can be incorporatedinto the medium in which the epinephrine is suspended. The approach forachieving the sustained or controlled release may be achieved withepinephrine and/or co-administered vasodilation agents.

In addition to enabling agents in both aqueous and powder intranasalformulations of the present invention, the composition may furthercontain preservatives, stabilizers, anti-oxidants, thickening agent,humectant, surfactants, mucoadhesive agents, colorants, one or moreexcipients or combinations thereof.

To achieve suitable shelf-life, epinephrine has conventionally beencombined with preservatives or stabilizers that themselves may beallergenic or even anaphylactic in some susceptible patients. Hence, inone embodiment, the composition of the present invention will be theonly formulation of epinephrine without these bronchospasmodicstabilizers and instead contain only Vitamin C as a stabilizer andsealed under inert nitrogen. The novel use of a naturally—occurringenzymatic stabilizing antioxidant system that is part of the human bodysolves a problem that has plagued the use of epinephrine, and a longlist of other drugs that degrade in the presence of oxygen.

In some other embodiments, the present invention may utilize naturallyoccurring thiols that do not have an unacceptable taste and smell. Inyet other embodiments, the present invention utilizes glutathionereductase as a naturally occurring recycling antioxidant to stop theoxidation of epinephrine in solution. It has the advantages of reactivesulfhydryl groups without the noxious smells or flavor of purifiedthiols, and unlike the purified thiols is enzymatic and self-generating.

In further embodiments, the pharmaceutical composition of the presentinvention is an isotonic non-irritating formulation for nasaladministration, and utilizes the enzymatic antioxidants ascorbic acid(natural vitamin C), glutathione, glutathione reductase and glutathioneperoxidase, under sterile nitrogen seal in solution in darkened vials,at concentrations known by those in the art. A similar antioxidantcycling system could also be set up with naturally occurring superoxidedismutase (CuZn—SOD) or superoxide reductase, with catalase or withnaturally occurring sulfur containing antioxidant enzymes including: (1)carnosine, a natural muscle enzyme used as a meat preserver; (2)ergothionene from fungi (but not mammals); (3) ovothiol from marineanimals and protozoa; (4) lipoic or thioctic acid (used to treatAmantita mushroom poisoning); and (5) thioredoxin peroxidase.Recombinant thermostable variants of these various enzymes would conferconvenience and shelf life on the enzymes themselves, and can be used inthis invention.

In one embodiment, the pharmaceutical composition of present inventionis a sterile single or dual-event premeasured, pre-mixed, sterilepreparation. In a related embodiment, a process for making a sterilenasal solution without preservatives, of the present invention comprisesone or more of the following steps: (1) adding at least atherapeutically effective pediatric or, alternatively adult, amount ofepinephrine and enabling drugs and other agents in a vehicle, such aswater; (2) placing the mixture in a container, and sterilizing themixture by steam sterilization, or by any other sterilization meansknown in the art. Each mixture being filled into a vial, and thenpackaged under nitrogen gas, sealed, stored and/or used directly. Here,the resulting mixture is stable, and after sterilization, it can bedispersed, if necessary, into multiple mixtures each containing a unitdose of a therapeutically effective amount of epinephrine and enablingdrugs suitable for adults or children.

In another embodiment, a process for making a non-sterile nasal solutionwith preservatives of the present invention comprises one or more of thefollowing steps: (1) adding at least a therapeutically effectivepediatric or, alternatively adult, amount of epinephrine in a vehicle,such as water; (2) adding stabilizers such as BAC, and either sodiummetabisulfite or ascorbic acids, in sufficient concentrations to achievea 12-24 month shelf life or more, as is known in the art. Each mixturebeing filled into a vial, and then packaged under nitrogen gas, sealed,stored and/or used directly. Here, the resulting mixture is stable, andcan be dispersed, if necessary, into multiple mixtures each containing aunit dose of a therapeutically effective amount epinephrine suitable foradults or children.

In some embodiments, osmotic adjusting agents may be used in the presentcomposition and include, but are not limited to, sodium chloride,potassium chloride, zinc chloride, calcium chloride, and mixturesthereof. Other osmotic adjusting agents may also include, but are notlimited to, mannitol, glycerol, and dextrose and mixtures thereof. In analternative embodiment, the present invention may comprise about 0.4 toabout 1.0 weight percent ionic salt. Preferably, the present inventioncomprises about 0.9 weight percent of an osmotic adjusting agent.

In some embodiments, the intranasal epinephrine formulations of thepresent invention could use a variety of taste-masking agents, includingcyclodextran cages to taste-mask the unpleasant taste of epinephrine(Simons F.E.R. et al. 2000, Pediatrics 106(5): 1040-44).

Pharmaceutical Product and Doses

In one preferred aspect, the present invention provides a pharmaceuticalproduct, comprising apparatus for intranasally administering apharmaceutical dose or dose form in accordance with the third aspect ofthe invention, and a pharmaceutical composition in accordance with thefirst or second aspect of the invention. The apparatus can comprise areservoir and means for expelling the pharmaceutical dose in the form ofa dry powder or aqueous spray, wherein a quantity of the pharmaceuticalcomposition is contained within the reservoir. In an embodiment, theapparatus comprises a pump spray device in which the means for expellinga dose comprises a metering pump or precise expulsion of the correctdose in a single use device. In an alternative embodiment, the apparatuscomprises a pressurized spray device, in which the means for expelling adose comprises a metering valve and the pharmaceutical compositionfurther comprises a conventional propellant. In some embodiments, thedevice used to deliver the present composition can be programmed or isprogrammable before use to deliver a pharmaceutical dose(s). The devicemay further have audio or visual features to either instruct the user todeliver a pharmaceutical dose and/or indicate the user after the dose isdispensed. Suitable pressurized spray devices are well known in the artand include those disclosed in, WO199211190, WO199709034, U.S. Pat. Nos.4,819,834, 4,407,481 especially when adapted for producing a nasal sprayas opposed to an aerosol for inhalation, or a sublingual spray. Suitablenasal pump spray devices include for instance, the VP50, VP70 and VP100models available from Valois S. A. in Marly Le Roi, France and the 50,70 and 100 μl nasal pump sprays available from Pfeiffer GmbH inRadolfzell, Germany, although other models and sizes can be employed. Inthe aforementioned embodiments, a pharmaceutical dose or dose unit inaccordance with the invention can be present within the metering chamberof the metering pump or valve.

As shown in Table 1, the currently available doses offered by EpiPen™result in physicians being forced to decide whether to underdose (i.e.,1.3-1.7X) or to overdose (i.e., 1.5-3.0 X) a patient based on weight,especially in children. The current invention also provides two nasalsprays: a higher dose for adults, and a lower dose for children.However, unlike Epipen™ that is marketed only in 2 fixed doses (0.15 mgfor pediatric use and 0.3 mg for adult use), the concentration ofepinephrine (the loading dose) administered in the present inventionimportantly allows the patient or healthcare professional to choose thenumber of sprays to administer to achieve the correct or optimal dosefor their particular body weight (Table 1). This can be achieved eitherby having several sprays from a multi-dose pump device or using severalsingle use pumps. Thus the formulation of the present invention has 2key advantages (i) permits attaining bioequivalent doses ofintramuscularly administered epinephrine for both children and adults(ii) permits optimal doses depending on the body weight of the subjectin contrast to under- or over dosed subjects using Epipen™.

TABLE 1 Illustrative Optimal Nasal Dosing at all Pediatric Weights

*Note that the nasal loading dose will be adjusted to give bloodbioequivalent doses for IM administration.

For instance, as shown in Table 1, assuming that the loading dose in thepresent formulation (in a Nasal Epinephrine Jr. nasal product) isbioequivalent to the IM systemic blood epinephrine levels (pediatricdose of Epipen™ is 0.15 mg/0.3 mL or 0.05 mg/100 a single spray could be0.05 mg dose per 100 μL and up to 3 sprays would deliver the bloodequivalent of an IM injection of 1.5 mg and 6 sprays (i.e.: 3 sprays pernostril) would deliver the blood equivalent of an intramuscularinjection of 0.3 mg in a pediatric patient weighing about 30 Kg. In theadult Nasal Epinephrine product, the initial dose would be bioequivalentof 0.3 mg intramuscular dosing, and if more was needed an additional 6sprays would be available. Naturally, these loading doses may beadjusted for the actual kinetics of nasal delivery in this compositionin order to achieve the bioequivalent of the intramuscular dose. Aftereach anaphylactic event, the disposable nasal spray device would bediscarded as the nitrogen seal would be broken and the unit would nolonger be sterile. This formulation and drug-device combination meetsthe mg/kg drug dosing flexibility that clinicians have been trying toachieve for many years. Unlike Primatene Mist, which took up to 20inhalation doses to come close to therapeutic levels (Simons F.E.R. etal. 2000 Pediatrics 106(5): 1040-44), each nasal spray can be manuallyactuated by either the patient or caregiver, and only 100-250 μL involume or 100 mg, requiring no inspiratory effort by the patient. Thepresent invention also permits utilizing the customizable ideal dosing(0.01 mg/kg body weight) according to the Tables 2 and 3 below.

TABLE 2 Illustrative Customizable Ideal Dosing for Children Drug Doseper Spray*** 1. PEDIATRIC: Nasal Sprays total* 1 2 3 4 5 6 PediatricBody weight (Kg) ≤5 10 15 20 25 ≥30 Epinephrine actual dose: 0.05 mg0.05 0.1 0.15 0.2 0.25 0.3 Optimal Dose: 0.05 0.1 0.15 0.2 0.25 0.3Phentolamine actual dose: 0.5 mg 0.1 1.0 1.5 2.0 2.5 3.0 Optimal Dose:0.6-30 mg/mL spray Entacapone actual dose: 0.1 mg 0.1 0.2 0.3 0.4 0.50.6 Optimal dose under 20 mg/spray

TABLE 3 Illustrative Customizable Ideal Dosing for Adults 2. ADULT**:Dosage is one spray, unless treatment a failure or rebound anaphylaxisrequires a second, to a maximum of four additional doses total forrefractory patient or rebound anaphylaxis; note that the loading dosesare illustrative and would be adjusted for bioequivalence to IMinjection of epinephrine Sprays total* 1 2 3 4 Adult Body weight (Kg)≥30 ≥60 ≥90 ≥120 Epinephrine actual dose: 0.3 mg 0.6 0.9 1.2 OptimalDose: 0.3 mg na na na Phentolamine actual dose: 0.5 mg 0.5 1.0 1.5Optimal Dose: 0.1-30 mg/mL spray Entacapone actual dose: 0.1 mg 0.1 0.20.3 Optimal dose: 0.1-20 mg/spray *Sprays divided between two nostrils;so for total 6 sprays, it is 3 sprays per nostril; for total 3 sprays,it is 2 sprays in one nostril, 1 spray in the other, and so forth. ForAdult dosing, there would be four total sprays of 0.3 g each sprayavailable, if the first spray were ineffective. *** Spray volume istargeted at 100 μL each spray.

This gives target concentrations of:

Dose per Spray Concentration* Pediatric Adult Pediatric AdultEpinephrine 0.05 g 0.30 g 0.5 mg/mL 1.0 mg/mL Phentolamine 0.5 mg 0.5 mg50 mg/mL 50 mg/mL Entacapone 0.1 mg 0.1 mg 10 mg/mL 10 mg/mL *Assume 100μL per dose spray

Therefore unlike the marketed intramuscular epinephrine injections thatare available in only two fixed doses of epinephrine, the nasal spraydosage can be adjusted 10-fold in pediatric use and 10-fold in adultuse, by administering only up to three sprays into each nostril,suitable for giving an exact ideal-body-weight-adjusted dose of eachdrug, without the need for mixing. This means that the patient canreceive the exact weight-matched optimal doses, or if non-responsive,additional doses. Additionally, the present formulation can be deliveredas a second dose from the same device in the case of reboundanaphylaxis. Finally, by intranasal administration of presentformulation the current invention obviates the documented problem thatthe increasing obesity epidemic has caused the length of the EpiPen™autoinjector needle to be insufficient to achieve intramuscular dosing,but rather subcutaneous dosing with the ineffective Tmax.

Herein, the loading dose (i.e., amount of epinephrine administerednasally) results in a bioequivalent dose (in terms of peripheral bloodlevels and systemic exposure of epinephrine) of intramuscularly injectedepinephrine, which is 0.15 in children and 0.3 mg in adults,respectively. Thus, the blood bioequivalent epinephrine target levels,and the loading doses of vasodilator and COMT inhibitor are a ratio of(epinephrine): (phentolamine): (entacapone) in the compositionsaccording to the invention is preferably within the range of (0.15 mg:0.5 mg; 0.1 mg) for pediatric dosing to (0.3 mg: 0.5 mg: 0.1 mg) foradult dosing. This may be increased six fold proportionately to give theestimated maximal blood doses (i.e., the blood equivalent ofintramuscularly injected EpiPen™), respectively.

Upon intranasal administration of the loading dose in either powder oraqueous form, the increase in epinephrine levels is at least the same orequivalent to intramuscularly injected epinephrine. In anotherembodiment, the increase in epinephrine levels in the blood is 2-foldmore than the baseline (i.e., levels prior to epinephrineadministration). In related embodiments, intranasal administration ofthe present composition elicits between 2-fold and 15-fold increase inthe epinephrine levels in blood within 30 minutes of saidadministration. In some embodiments, the increase in epinephrine levelsis observed within 15 minutes, or preferably within 10, 5, 3, 2, and 1minute and the level is sustained in the blood for at least 90, 60, 30,20 minutes after administration. In further embodiments, the increasedepinephrine concentration in the blood is sustained for 60, 40 and 30minutes.

Therapeutic Methods of Using the Formulation in the Treatment ofAnaphylaxis

The present invention provides methods of reducing an anaphylacticreaction in an individual, methods of reducing a symptom of anaphylaxis,methods of reducing the risk of a full-blown anaphylactic response,bronchospasm, and cardiac arrest in an individual, or for treating asubject in cardiac arrest outside ER or in the battlefield or duringhypotensive shock and methods of reducing the incidence of the same. Themethods generally comprise administering an effective amount of thecompositions of the present invention to the mucosal surfaces of thenasal cavities of an individual. The methods are useful to treat ananaphylactic response. Accordingly, the invention further providesmethods of treating anaphylaxis in an individual.

Pharmaceutical compositions, doses or products in accordance with thepresent invention are useful in the treatment of human conditions knownto be responsive to epinephrine, including anaphylaxis, and for rescuinga subject in bronchospasm or cardiac arrest. They also provide a fastonset time and are suitable for intranasal use. Although not wishing tobe bound by any particular theory, it is considered that the capacity ofcompositions in accordance with the present invention for providing highblood plasma epinephrine concentrations very rapidly afteradministration, on the basis of optimal doses of epinephrine, leads totheir enhanced efficacy and reduces the likelihood of any unwanted sideeffects being caused.

In a yet further aspect of the present invention, there is provided theuse of epinephrine in combination with one or more enabling agents,mucosal penetration agents, mucosal transit agents, for the preparationof a pharmaceutical composition, dose or product in accordance with anypreviously described aspect of the invention, for treating anaphylaxis,or bronchospasm or during CPR. The preferred unit dose is 0.05 mg to 10mg epinephrine, 0.001 mg to 10 mg of entacapone and/or 0.001 mg to 10 mgphentolamine. For making dose units, any pharmaceutically acceptableadditives or excipients that do not interfere with the function of theactive ingredients can be used.

The invention is further illustrated by the following examples.

The following compositions are prepared as illustrative aqueoussolutions of the named drugs suitable for use as nasal drops of nasalspray. In each case, the pH of the final composition is adjusted withpharmaceutically acceptable acid or base to achieve a pH in the range ofpH 3 to 9, for example in the range of pH 4 to pH 8, for example in therange of pH 7 to 8. The final osmolality of the formulation is adjustedwith a pharmaceutically acceptable tonicifying agent, for example sodiumchloride, to achieve a final in osmolality in the range of 10 to 2000mOsm/kg, for example in the range of 50 to 1000 mOsm/kg, for example inthe range of 100 to 500 mOsm/kg, for example in the range of 270 to 330mOsm/kg (the latter representing isotonic case).

Example 1 Specific Aqueous Intranasal Formulation ContainingEpinephrine, Entacapone and Phentolamine

To obtain the desired intranasal composition for the treatment ofanaphylaxis or bronchospasm, a specific aqueous intranasal formulationmay be formulated using nanoformulated reagents in volumes up to 250 μl,and other vasodilators or reversible COMT inhibitors at appropriateconcentrations. An aqueous composition comprised of the followingcomponents (per 1 mL volume):

-   0.5-100 mg epinephrine,-   1 mg polysorbate 80,-   2 mg methylcellulose,-   0.08 mg entacapone,-   0.5 mg phentolamine hydrochloride,-   sodium chloride q.s. to provide osmolality in the range of 200 to    350 mOsm/kg, and-   hydrochloric acid q.s. to adjust pH to 3.5-5.0. The aqueous    composition is sterile filled into a vial affixed with a nasal    aqueous spray pump for delivery of 0.1 mL of atomized product per    discharge at a fill volume sufficient to provide at least 2 doses.

In another embodiment of this example, an aqueous composition compriseof the following components (per 1 mL volume):

-   0.5 mg epinephrine maleate,-   1 mg polysorbate 80,-   2 mg methylcellulose,-   1 mg dipivefrin hydrochloride as vasodilator,-   sorbitol q.s. to provide osmolality in the range of 200 to 350    mOsm/kg, and citric acid q.s. to adjust pH to 5.0 - 7.0. The aqueous    composition is sterile filled into a vial affixed with a nasal spray    pump for delivery of 0.1 mL of atomized product per discharge at a    fill volume sufficient to provide at least 2 doses.

In certain other embodiments of this example, the epinephrine asdescribed in the aqueous formulation above is epinephrine hydrochlorideor epinephrine maleate and the amount present in 1 mL of the compositionpreferably is, 0.5 mg or 1.5 mg or 1.75 mg or 2.5 mg or 2.75 mg or 3.0mg or 3.5 mg or 4.0 mg or 4.5 mg or 5.0 mg or 10.0 mg or 15.0 mg or 20.0mg or 25.0 mg or 30.0 mg or 35.0 mg or 40.0 mg or 45.0 mg or 50.0 mg or55.0 mg or 60.0 mg or 65.0 mg or 70.0 mg or 75.0 mg or 80.0 mg or 85.0mg or 90.0 mg or 95.0 mg or 100 mg.

The above-described formulations may additionally contain 1 mg DDPC, 1mg EDTA and 10 mg methyl-beta-cyclodextrin as nasal permeationenhancers.

Example 2 Dry Powder Formulation of Epinephrine

A 20 mg dry powder formulation is prepared from the followingingredients: 0.15 mg or 0.3 mg or 0.75 mg or 1 mg epinephrine powder(from SIGMA-ALDRICH) mixed with one or more enabling agents including0.0001 mg or 0.1 mg entacapone (a reversible COMT inhibitor) and/or0.0001 mg or 0.5 mg phentolamine (vasodilator) and 1.5 mg suitablecarrier, for instance lactose, and suitable penetration enhancer andmucosal transit agent. The average particle diameter of each of theingredient is within 30 μm. The sterile formulation can then be packagedinto vials or nasal spray devices for delivery into nasal mucosa of testsubjects.

Testing of Dry Powder Formulation

The pharmacokinetic study of intranasal dry powder epinephrineformulations will be tested in animal models such as cynomolgus(macaque) monkeys. The animals (approximately, 5-7 in no.) will behandled in compliance with the Animal welfare Act and will be examinedand evaluated at regular intervals by study personnel. Enough care willbe taken to ensure no test-article related abnormalities are noticed inany macaque. Before the experiment, the animals will be divided intofollowing groups:

-   control 1 (IM placebo),-   control 2 (intranasal spray with carrier only)-   test group 1 (IM epinephrine)-   test group 2 (intranasal spray of epinephrine and suitable carrier),-   test group 3 (intranasal spray of epinephrine, carrier and    entacapone) or-   test group 4 (intranasal spray of epinephrine, carrier and    phentolamine)-   and will be anesthetized by injection of suitable anesthetic, for    example, tiletamine/zolazepam (6 mg/kg). Animals in test group 1    will receive an IM injection of 0.15 mg and those in test group 2    will receive a 20 mg dry powder nasal spray of a composition    containing, either 0.75 mg, 1.5 mg or 3.0 mg of epinephrine. Animals    in test group 3 will receive 1.5 mg of epinephrine and 0.001 mg or    0.01 mg or 0.5 mg of entacapone while those in test group 4 will    receive 1.5 mg epinephrine and 0.5 mg or 0.75 mg of phentolamine.    The carrier present in the composition can be lactose or any other    pharmaceutically acceptable excipients or enabling agents disclosed    in the present invention. When multiple doses are investigated, the    animals will be allowed to recover for at least 7- 10 days between    each dosing. Blood samples from each group will be collected    pre-dose, 2, 3, 5, 8, 10, 15, 20, 25, 30, 45, 60, 90, 120 and 180    minutes after dosing and the epinephrine concentrations in the blood    plasma shall be analyzed.

Example 3 Nano-Formulation of Epinephrine (Powder) for AqueousReconstitution Before Use

U.S. Pat. No. 7,078,057 B2 by Kerkhof is referenced herein in itsentirety with regards to the nanoformulation method of preference. Inthis disclosure, fluid bed spray drying is employed to manufacture pureAPI into uniform and stable 40-80 nm particles. These particles can beprovided for direct intranasal formulation.

In another embodiment of this example, the nanoformulated epinephrineparticles are blended with larger particles of a suitablepharmaceutically acceptable carrier, for instance lactose. For example,the nanoformulated epinephrine coated lactose particles is in the sizerange (i.e., Dv, 50) of 10 microns to 500 microns, for example in therange of 30-100 microns, for example about 50 microns. It is desired tominimize the fraction of nanoformulated epinephrine coated lactose withsize less than 10 microns, for example no more than 10% of particleswith size less than 10 microns, for example no more than 1% of particleswith size less than 10 microns.

In another embodiment of this example, the nanoformulated epinephrinealso contains a vasodilation agent which can be incorporated into thesame nanosized particles containing epinephrine, or can be producedseparately as nanoparticles, then subsequently the epinephrinenanoparticles and the vasodilating agent nanoparticles can be blended asa co-mixture; both of these cases can also be envisioned to be furtherblended with lactose particles in order to provide a particle sizesuitable for nasal administration.

Example 4 Nanoformulation of Epinephrine (Suspension)

U.S. Pat. No. 7,078,057 B2 by Kerkhof is referenced herein in itsentirety with regards to the nanoformulation method of preference. Inthis disclosure, fluid bed spray drying is employed to manufacture pureAPI into uniform and stable 40-80 nm particles. These particles can befurther formulated as a suspension for intranasal administration at thetime of use. Such a nasal reformulation device can have the aqueous andnanoformulated dry powder mix at the time of the plunger activation. Thesuspension milieu can contain various pharmaceutically acceptableexcipients, permeation agents, mucosal transit agents, includingsolvents, pH agents, stabilizers, tonicifying agents, viscosityenhancing agents, dispersing agents such as surface active agents, nasalabsorption enhancers, chelators, and preservatives. Alternatively, thesuspension nanoformulation of epinephrine can be preservative free.

Example solvents for the suspension nanoformulation of epinephrineinclude water, and non-aqueous solvents such as ethanol, and lowmolecular weight poly (ethylene glycols). Agents for adjusting pH insuspension nanoformulation of epinephrine include buffer systems. Saidbuffer systems include, but are not limited to, acetate, citrate,succinate, phosphate, amino acids, and tromethamine. Pharmaceuticallyacceptable acid or base can be added to achieve a pH in the range of pH3 to 9, for example in the range of pH 4 to pH 8, for example in therange of pH 7 to 8.

Example stabilizers for the suspension nanoformulation of epinephrineinclude sugars and other polyols, amino acids, and various antioxidantas described in detail herein.

Example tonicifying agents for the suspension nanoformulation ofepinephrine includes pharmaceutically acceptable sugars and otherpolyols (such as, but not limited to, trehalose, mannitol, and sorbitol)and salts (such as, but not limited to, sodium chloride). The finalosmolality of the formulation is adjusted with a pharmaceuticallyacceptable tonicifying agent, for example sodium chloride, to achieve afinal in osmolality in the range of 10 to 2000 mOsm/kg, for example inthe range of 50 to 1000 mOsm/kg, for example in the range of 100 to 500mOsm/kg, for example in the range of 270 to 330 mOsm/kg (the latterrepresenting isotonic case).

Example 5 Blended Aqueous Epinephrine Formulation

U.S. Pat. No. 6,702,997 teaches the production of a pulmonary liquidinhalation nebulized spray for pediatric asthmatic patients. In thisexample, their target concentrations for the nebulizer solution were0.63 mg/3 mL or 1.25 mg/3 mL for pediatric dosing. In contrast, thepresent invention targets a highly concentrated solution of epinephrine,so that the effective dose is not 3 mL but about 100 uL. To achieve thislevel of solubility of the drug with the COMT inhibitor and vasodilator,mucosal transport agents, mucosal transit agents, as well as theenzymatic antioxidants (hereafter excipients), either (1) as a sterilesolution bottled under nitrogen gas in opaque bottles, or (2) as anon-sterile solution with added preservatives bottled under nitrogen inopaque bottles, we have employed strategies to achieve highconcentrations of the drugs in aqueous solution. These include the useof PEG, lipid and zwitterionic solubilizers, the use of alternativesalts of the active drugs, as well as specific nasal mucosal tightjunction permeation agents. Such agents include, but are not limited to,chelators (such as EDTA), surface-active agents (such as DDPC orTween-20 or Tween-80), tight junction modulating peptides, andcyclodextrins.

Herein is described the process for making a single unit dose, sterile,premixed, premeasured and preservatives-free solution for the fixed dosecombination (FDC) for nasal epinephrine and the enabling drugs andexcipients for the treatment of anaphylaxis. In such an embodiment, themethod of the present invention comprises one or more of the followingsteps: (1) adding at least a therapeutically effective pediatric or,alternatively adult, amount of epinephrine and excipients in a vehicle,such as water; (2) optionally sterilizing the solution and sealing thecontainer. An osmotic adjusting agent may be added to adjust theisotonicity of the solution. In one embodiment of the present invention,the solution of the present invention is isotonic. Isotonicity may beachieved by adding an osmotic adjusting agent to adjust the isotonicityof the solution from about 280 to about 320 mOsm/kg. In addition, anacid (e.g., sulfuric acid) may be added to adjust the pH of the solutionto between 3.0 to about 4.0, preferably at about 3.5.

In an alternative embodiment, the nasal solution of the presentinvention may be prepared as follows: (1) fitting a high densitypolyethylene (HDPE) or stainless steel formulation tank with a bottomdrain and peristaltic recirculation system (for HDPE) or tri-blender(for stainless steel) for mixing; (2) filling the tank withapproximately 90% of the required amount of Purified Water USP at atemperature of between 18.degree. C to 25. degree. C; while mixing; (3)adding sulfuric acid, Sodium Chloride USP, and at least atherapeutically effective amount of pediatric Epinephrine USP andexcipients to the tank; (4) continue mixing until all chemicalcomponents are dissolved; (5) adding Purified Water USP to adjust thefinal volume, if necessary, thus producing the epinephrine mixture. Fromthe formulation tank, the epinephrine mixture is pumped out throughsanitary delivery lines directly into a form-fill-seal (FFS) machine.The epinephrine mixture passes through a 0.2 micron sterilizingcartridge filter, to the filling nozzles within the sterile air showercompartment, and subsequently into formed vials of glass or low densitypolyethylene (LDPE) that have been silkscreened to prevent lightentering. The epinephrine mixture being sterile filled under nitrogengas into the vials such that each vial contains a single unit doses perpump action of a therapeutically effective amount of epinephrinesuitable for adults and children. The filled vials are then sealed. Themachine may form, fill and seal the vials in a continuous operationunder aseptic conditions, thus producing a sterile product. For example,cards of five filled vials are overwrapped into a protective laminatedfoil pouch using an auto wrapper machine. Five to twelve such pouchesmay then be packaged in a shelf carton, thus forming a prepackagedtherapeutic system for relieving anaphylaxis, cardiac arrest andbronchospasm. An appropriate label and instructions may be added in theshelf carton.

In an alternative embodiment of the present invention, the epinephrinesolution with or without the added preservatives is still filled undernitrogen gas, but not under sterile conditions.

I claim:
 1. A pharmaceutical composition comprising: (a) an anti-anaphylactic agent, wherein the anti-anaphylactic agent is epinephrine, and (b) a vasodilator, wherein the vasodilator is phentolamine, wherein said composition is an aqueous formulation with a pH in the range of 3 to 9, and the formulation provides a dose of about 0.05 mg to about 10 mg of epinephrine and about 0.001 mg to about 10 mg of phentolamine for a human patient.
 2. The pharmaceutical composition according to claim 1, further comprising one or more agents selected from the group consisting of, pharmaceutically acceptable excipients, epinephrine potentiators, mucosal permeation or penetration enhancers, mucosal transit slowing agents, mucosal absorption or transport enhancers, mucoadhesives, non-sulfite stabilizers, preservatives, thickening agents, humectants, antihistamines, solubilizing agents, taste-masking agents, antioxidant enzymes, viscosity enhancing agents, dispersing agents, or any combination thereof.
 3. The composition according to claim 1, further comprising a reversible COMT inhibitor, wherein the reversible COMT inhibitor is entacapone, or its pharmaceutically acceptable salt or prodrug thereof.
 4. The composition according to claim 3, wherein the amount of entacapone is about 0.008 mg to about 0.2 mg per kg body weight of a the human patient.
 5. The composition as in claim 1, wherein the composition is formulated as a nasal spray characterized for a single or multiple use.
 6. The composition as in claim 1, wherein the composition is configured to be used in the treatment of a condition selected from the group comprising, anaphylaxis, bronchospasm and cardiac arrest.
 7. A pharmaceutical product comprising, a device for intranasal administration dispensing a pharmaceutical composition, wherein the pharmaceutical composition comprising: (a) an anti-anaphylactic agent, wherein the anti-anaphylactic agent is epinephrine, and (b) a vasodilator, wherein the vasodilator is phentolamine, wherein said composition is an aqueous formulation with a pH in the range of 3 to 9, and the formulation provides a dose of about 0.05 mg to about 10 mg of epinephrine and about 0.001 mg to about 10 mg of phentolamine for a human patient.
 8. The pharmaceutical product of claim 7, wherein the device comprises a reservoir and means for expelling the pharmaceutical composition in the form of a spray, wherein a quantity of the pharmaceutical composition is contained within the reservoir.
 9. A method of treating anaphylaxis or bronchospasm or cardiac arrest in a subject, wherein the method comprises administering intranasally a pharmaceutical composition comprising: (a) an anti-anaphylactic agent, wherein the anti-anaphylactic agent is epinephrine, and (b) a vasodilator, wherein the vasodilator is phentolamine, wherein said composition is an aqueous formulation with a pH in the range of 3 to 9, and the formulation provides a dose of about 0.05 mg to about 10 mg of epinephrine and about 0.001 mg to about 10 mg of phentolamine for a human patient.
 10. The method of claim 9, wherein the pharmaceutical composition further comprises agents selected from the group comprising pharmaceutically acceptable excipients, epinephrine potentiators, mucosal permeation or penetration enhancers, mucosal transit slowing agents, mucosal absorption and transport enhancers, mucoadhesives, non-sulfite stabilizers, preservatives, thickening agents, humectants, antihistamines, solubilizing agents, taste masking agents, antioxidant enzymes, viscosity enhancing agents, dispersing agents, or any combination thereof.
 11. The method of claim 9 further comprises adjusting a dose of the epinephrine according to the weight of the subject at an increment of at least 0.01 mg/kg or repeating the dose of the epinephrine more than once if the subject is refractory or experiences rebound anaphylaxis. 